PERSONAL DATA CHANGE FORM
Submit to the Registraon Oce
SITE: Fort Steilacoom
Fort Lewis
Puyallup
McChord
COMPLETELY FILL IN THIS PORTION OF THE CHANGE FORM
STUDENT ID #
LAST NAME FIRST NAME MI
BIRTHDATE (MM/DD/YYYY)
DAY PHONE #
LAST QUARTER ATTENDED:
SUMMER FALL WINTER SPRING YEAR_______
CURRENTLY ENROLLED
YES NO
FILL IN ONLY THE SECTIONS THAT NEED TO BE CHANGED
*LAST NAME FIRST NAME MI
*Name Change: Both Driver’s License and SS Card showing new name, or marriage/divorce docs, passport or cered court docs.
Check this box if you do not want
your student email updated to
the new name.
DAY PHONE #
EVENING PHONE #
BIRTHDATE (MM/DD/YYYY)
STREET ADDRESS CITY STATE ZIP
SOCIAL SECURITY NUMBER*
*Requires SSN Card
OTHER/MISCELLANEOUS CHANGE (Please be specic)
Student’s Signature (REQUIRED) Date
Note: All data changes require picture idencaon in addion to supporng legal documentaon.
Cizenship Change: Naturalizaon Cercate, Green Card/Permanent Resident Card, etc.
Shaded Area for
Oce Use ONLY
Date Received:
_______________________
Change Completed
Comment in SM4015
Contact HelpDesk for Email
Update
Inials/Date
_______________________
Final Check/Clean up:
(Inials/Date)
click to sign
signature
click to edit
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